P - 41750Engineering WATER AND SEWER Permit No.: � v f ��
763-572-3552 PERMIT APPLICATION Received By: �
763-571-1287 fax CITY OF FRIDLEY �/� �(�
EFFECTIVE Ol/Ol/2011 Da���--t���l 1
APPLICATION DATE: ���� YOUR E-MAIL/FAX: _
THIS APPLICANT IS: ❑ OWNER C�(CONTRACT R
JOB ADDR6SS: tio Z`� Z.� ��•
NEW CONSTRUCTION PERMIT# (IF APPLICABLE):
PROPERTY NAME: � a t � r, u� �- Gv+ � e r-
OWNER/ Ai�DRESS: CITY STATE ZIP
TENANT
PHONE:
CONTRACTOR NAME: rr> < </'
SUBMIT A COPYOF ADDRESS: °?'7 ,S' ']rjo .w-, Q CITY ;''V,Kiff STAT ZIPSS3 � a
YOUR ST.9TE '1 %� —�
LICENSE WITH PHONE 7� 3•- � i,�� %v'} �� CELL PHONE: �� '�- - Z 3'7 ^ iG � S'�-
APPLICATION
STATE LIC # STATE BOND: EXP DATE:
1. Narrative/wr' ten descriptipn: f � � �
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2. Please attach sketch showing curb line, utility line, building, etc. with distances on back page.
3. Stipulations: j. �/,L�-'Cll� c����CX.�, l.� (�.��s� Ze (�/�i��nr�e.��-c_c+�`
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PERMIT YPE • 76� - ���' >Sip
— 3552
C SEWER CONNECTION PERMIT Cl SEWER DISCONNECT PERMIT $50 ��d— d58
� WATER CONNECTION PERMIT ❑ WATER DISCONNECT PERMIT $50
❑ WATER LINE REPAIR $40 p
❑ SEWER LINE REPAIR $40
❑ ADD STATE SURCHARGE $5.00 for each permit
❑ SAC CHARGE @ $2230 =
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TOTAL $ ��
OTHER CHARGES (IF APPLICABLE) PAY TO UTILITY BILLING
NEW WATER I�TER COST - SEE UT[LITY BILLING
SPECIAL ASSESSMENTS - SEE FINANCE
WATER TAP - SEE ENGiNEERING
NOTE: WATER METER REPAIR, INSP OR SHUT-OFF / EVENINGS, WEEKENDS & HOLIDAYS $125/HOUR-BILLED
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a water or sewer (new connection or repair) permit and I acknowledge that the information above is complete and
accurate; that the work will be in conformance with the ordinances and codes of the City of Fridley. I understand this is not a permit but
only an application for a permit a ork is ot to st rt without a permit.
SIGNATURE OF AP ICANT PRINT NAME: Y�/G DATE: � L/ ��
APPROVED BY: � DATE: !v I �
COPY GI T:❑ TILITY BILLING (only if new meter) ❑ PUBLIC WORKS ❑ ENGI EE ING
City of Fridley
Engineering Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3552
FAX: 763-571-1287
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